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Postoperative Complications of Frontal Sinus Fractures: A Retrospective Review of 47 Cases
Oral Abstract Session 4 PMMA cranioplasties placed. The average age of the patients at the time of surgery was 42 years. The predominant mechanism of injury was trauma (67%). Followed by ruptured aneurysm (14%), tumors (8%), hematoma (5%), epilepsy (4%), CVA 1 (1%) and brain abscess (1%). Fifty-seven of the 78 had no repair at the time of injury. Thirteen were originally repaired with replacement of the bone flap, which was then later removed. The remaining 8 were failed PMMA cranioplasties as noted above. The average time of follow up was 327 days with a range from 0 (lost to follow-up) to 2,495 days. The most frequent post-operative complication was infection (17%). The patients returned for the infected cranioplasty between 15 and 507 days post-op (average 103). Five of the 13 infected cranioplasties were in the bilateral frontal area. The remaining were unilateral; 5 in the frontal-temporal-parietal region, 2 frontal-parietal, and 1 parietal. Seven post operative hematomas occurred between days 1 through 8 (average 2) with 3 evacuated surgically and replacement of the cranioplasty. One migration of the implant occurred on day 30, after the patient had a seizure and fell, which required repositioning. Two scalp erosions and exposure of the implants occurred on days 3 and 21. Nine patients experienced chronic headaches postoperatively. One patient had chronic postoperative pain attributed to temporalis muscle spasms. With the exception of the 2 patients with implant exposure, no patients reported an unacceptable cosmetic result. Overall, a total of 14 (18%) of the 78 were removed. Conclusions: The results of previous studies have shown that infection and complication rates of cranioplasties accomplished with bone cement are substantially higher, titanium based implants obscure follow-up imaging, and that the outcomes regarding HA-based ceramics while similar (in matched populations) to PMMA, are associated with a much higher cost. PMMA remains a cost effective and proven method to repair cranial defects that fulfills the goals of cranial reconstruction for skull defects. References: Gooch MR, et al: Complications of Cranioplasty Following Decompressive Craniectomy: analysis of 62 cases. Neurosurg. Focus, June 2009, 26 1-7. Moreira- Gonzalez A, et al: Clinical Outcome in Cranioplasty: Critical review in long-term follow- up. The Journal of Craniofacial surgery. March 2003, 14(2) 144- 153.
Postoperative Complications of Frontal Sinus Fractures: A Retrospective Review of 47 Cases C. Sauve´: Ho ˆ pital de l’Enfant-Je´sus, R. Paquin, A. Valcourt Statement of the Problem: Management of frontal sinus fractures is one of the most controversial subjects e-36
in oral and maxillofacial surgery. Theses fractures often occur in severely traumatized patients and since cerebral lesions are frequently part of the assessment, avoidance of complications is one of the main goals. No clear protocol has yet been established in the literature. The aim of the study is to evaluate the incidence of frontal sinus fractures over a 5-year period and the outcome of cases treated in our hospital. Materials and Methods: Between January 2003 and December 2008, a retrospective chart review of patients treated surgically for a frontal sinus fracture was performed. The recorded parameters included age, gender, etiology and sign and symptoms at admission. Fractures were divided according to involvement of anterior and posterior walls, presence of cerebral lesions and injury to the nasofrontal duct. The study also focused on treatment modality, obliteration material and type of complications. Statistical description was completed with a Fisher test or an exact 2 test. Results: During the study period, 47 cases of frontal sinus fractures treated in the department of Oral and Maxillofacial Surgery at Ho ˆ pital de l’Enfant-Je´sus in Quebec City were identified. The mean age of the patients was 31.5 years old, with a male predominance (85.1%). Frontal sinus fractures resulting from motor vehicle accidents was the most common (61.7%), following by sports (21.3%). Thirty-four patients had frontal cutaneous lacerations on arrival (72.3%), 38 had a step defect (80.9%) and 32 had periorbital ecchymosis (68.1%). Only 3 cerebrospinal leaks were noted upon examination (6.4%). Twenty isolated anterior table fractures were identified (42.6%) and none had only a posterior table fracture. Out of the 27 fractures involving the anterior and posterior tables (57.5%), 4 cases were treated by open reduction and internal fixation of the anterior table (14.8%), 8 cases underwent frontal sinus obliteration (29.6%), and 14 cases had a cranialization procedure (51.9%). Pericranium was the preferred material for obturation (72.4%). Complications occurred more frequently in patients treated by cranialization. Four patients suffered from postoperative infection (8.5%), 4 patients had esthetic deformities (8.5%), 4 patients complained of anosmia (8.5%), and 1 patient had a permanent temporal nerve paresis after treatment (2.1%). Only 1 case needed a lumbar drain for a postoperative fluid leakage. No brain abscess, meningitis or mucocele occurred during the 5-year period of follow-up. Conclusion: Although a limited-span retrospective study, our experience in frontal sinus fracture management seems to show fewer major cranio-cerebral complications than currently reported in the literature. Prospective study of a structured protocol could isolate and demonstrate the factors of our apparent improved performance. AAOMS • 2011
Oral Abstract Session 4 References: Bell RB, Dierks EJ, Brar P, et al: A protocol for the management of frontal sinus fractures emphasizing sinus preservation. J Oral Maxillofac Surg 2007 May; 65(5): 825-39. Strong EB, Pahlavan N, Saito D: Frontal sinus fractures: A 28-year retrospective review. Otolaryngol Head Neck Surg 2006 Nov; 135(5): 774-9.
Retroparotid Transmasseteric Approach to Condylar Fracture Through MiniRetromandibular Access S. Shah: Faculty of Dentistry, University of Manitoba, S. Ali, A. Mirza Statement of the Problem: The incidence of condylar fractures amongst mandibular fractures is between 17.5% and 52%. Almost 50% of condylar fractures have other associated fractures and 80% of them are unilateral fractures. Most are not caused by direct trauma but from indirect forces transmitted to condyle from elsewhere. Broadly there are 2 types of fractures, intracapsular and extracapsular, but for diagnostic and practical reasons it has been divided into 3 categories: condylar head (intracapsular), the condylar neck (extracapsular) and the subcondylar fractures. They are classified as: undisplaced, deviated, displaced (with medial or lateral overlap) and dislocated. The management of mandibular condylar fractures remains controversial. A wide spectrum of management is seen from plain analgesic, to physiotherapy, intermaxillary fixation and open reduction with internal fixation. Over the past decade better understanding of biological considerations of condylar fractures, improved surgical facilities and skills have tilted the balance in favor of open reduction. Open reduction is usually carried out by extra-oral approach such as preauricular, submandibular and retromandibular. Various modifications have been proposed for retromandibular approach like transparotid, transmasseter, high cervical transmasseteric anteroparotid, and mini retromandibular. This talk will present our experience with the retro-parotid transmasseteric approach to condylar fractures through mini-retromandibular access. This approach minimizes nerve injury and provides good access. Materials and Methods: From 2004 to 2010 a total number of 46 patients with a total of 51 condylar process fractures were treated with open reduction and internal fixation. Male patients were 36 and female 10 with an age range from 18 years to 52 years. Mean age was 32 years. The mechanism of injury was either motor vehicle accident, falls or assault. 7 cases were high condylar neck fractures, 28 low condylar neck and 16 were subcondylar fractures. Bilateral condylar fractures were 5. Condylar fractures associated mid-face fractures were 6, mandibular ramus and coronoid process 1, mandibular body and parasymphysis 29 and isolated condyle 15. Diagnosis was made on clinical and radiographic picAAOMS • 2011
tures, making use of panorex views, mandibular series x-rays and coronal CT scans. Indication for surgery included shortened posterior mandibular height, premature contact of molar teeth, presence of malocclusion like crossbite and anterior open bite and patient willingness through informed consent. All patients were operated on using retroparotid tranamasseteric approach through mini retromandibular incision measuring between 1.5 to 2 cm. Maximum follow-up period was 4 years. Methods of Data Analysis: Descriptive statistics, Minitab 13. Results of Investigation: Good results were achieved. Posterior mandibular height was restored in all except one. No mandibular deviation was observed on opening in 45 patients. Occlusion and range of mandibular motion was found to be satisfactory. Facial symmetry was achieved in all patients. Transient facial nerve injury was noted in 4 patients which completely resolved in 6 to 8 weeks. One patient with bilateral facture encountered postop infection on one side which was treated with antibiotics. Salivary fistula was present in 2 patients treated conservatively. Temporoandibular joint pain was reported by 3 patients of whom 2 were known to have nocturnal buxism. Condylar dislocation post ORIF was seen in 1 patient who experienced an epileptic fit. One plate was found fractured on a review appointment 12 weeks postop. All patients had minimally visible scar. Conclusion: Open reduction of condylar fractures through retroparotid transmasseteric approach via miniretromandibular access provides adequate exposure and reduction, minimal nerve injury and minimal visible scar. References: High Cervical Transmasseteric Anteroparotid approach for open reduction and internal fixation of condylar fractures. J Oral Maxillofac Surg.66:201-204.2008 Clinical followup examination of surgically treated fractures of the condylar process using transparotid approach. J Oral Maxillofac Surg: 68.611-617,2010
Subcranial Navigation-Assisted Repair of Frontobasal Skull Fractures S. Gelesko: Oregon Health and Science University; Legacy Emanuel Medical Center, R. Bell, E. Dierks, B. Potter Statement of the Problem: The management of frontobasar fractures with orbital roof involvement has historically been transcranial, with multiple potential complications including brain injury, significant bleeding, and poor esthetic outcomes. The primary objective of this retrospective cohort study was to determine whether displaced frontobasal skull fractures involving the orbital roof may be safely and successfully repaired via a navigation-assisted transorbital approach. The sece-37
Postoperative Complications of Frontal Sinus Fractures: A Retrospective Review of 47 Cases C. Sauve´: Ho ˆ pital de l’Enfant-Je´sus, R. Paquin, A. Valcourt Statement of the Problem: Management of frontal sinus fractures is one of the most controversial subjects e-36
in oral and maxillofacial surgery. Theses fractures often occur in severely traumatized patients and since cerebral lesions are frequently part of the assessment, avoidance of complications is one of the main goals. No clear protocol has yet been established in the literature. The aim of the study is to evaluate the incidence of frontal sinus fractures over a 5-year period and the outcome of cases treated in our hospital. Materials and Methods: Between January 2003 and December 2008, a retrospective chart review of patients treated surgically for a frontal sinus fracture was performed. The recorded parameters included age, gender, etiology and sign and symptoms at admission. Fractures were divided according to involvement of anterior and posterior walls, presence of cerebral lesions and injury to the nasofrontal duct. The study also focused on treatment modality, obliteration material and type of complications. Statistical description was completed with a Fisher test or an exact 2 test. Results: During the study period, 47 cases of frontal sinus fractures treated in the department of Oral and Maxillofacial Surgery at Ho ˆ pital de l’Enfant-Je´sus in Quebec City were identified. The mean age of the patients was 31.5 years old, with a male predominance (85.1%). Frontal sinus fractures resulting from motor vehicle accidents was the most common (61.7%), following by sports (21.3%). Thirty-four patients had frontal cutaneous lacerations on arrival (72.3%), 38 had a step defect (80.9%) and 32 had periorbital ecchymosis (68.1%). Only 3 cerebrospinal leaks were noted upon examination (6.4%). Twenty isolated anterior table fractures were identified (42.6%) and none had only a posterior table fracture. Out of the 27 fractures involving the anterior and posterior tables (57.5%), 4 cases were treated by open reduction and internal fixation of the anterior table (14.8%), 8 cases underwent frontal sinus obliteration (29.6%), and 14 cases had a cranialization procedure (51.9%). Pericranium was the preferred material for obturation (72.4%). Complications occurred more frequently in patients treated by cranialization. Four patients suffered from postoperative infection (8.5%), 4 patients had esthetic deformities (8.5%), 4 patients complained of anosmia (8.5%), and 1 patient had a permanent temporal nerve paresis after treatment (2.1%). Only 1 case needed a lumbar drain for a postoperative fluid leakage. No brain abscess, meningitis or mucocele occurred during the 5-year period of follow-up. Conclusion: Although a limited-span retrospective study, our experience in frontal sinus fracture management seems to show fewer major cranio-cerebral complications than currently reported in the literature. Prospective study of a structured protocol could isolate and demonstrate the factors of our apparent improved performance. AAOMS • 2011
Oral Abstract Session 4 References: Bell RB, Dierks EJ, Brar P, et al: A protocol for the management of frontal sinus fractures emphasizing sinus preservation. J Oral Maxillofac Surg 2007 May; 65(5): 825-39. Strong EB, Pahlavan N, Saito D: Frontal sinus fractures: A 28-year retrospective review. Otolaryngol Head Neck Surg 2006 Nov; 135(5): 774-9.
Retroparotid Transmasseteric Approach to Condylar Fracture Through MiniRetromandibular Access S. Shah: Faculty of Dentistry, University of Manitoba, S. Ali, A. Mirza Statement of the Problem: The incidence of condylar fractures amongst mandibular fractures is between 17.5% and 52%. Almost 50% of condylar fractures have other associated fractures and 80% of them are unilateral fractures. Most are not caused by direct trauma but from indirect forces transmitted to condyle from elsewhere. Broadly there are 2 types of fractures, intracapsular and extracapsular, but for diagnostic and practical reasons it has been divided into 3 categories: condylar head (intracapsular), the condylar neck (extracapsular) and the subcondylar fractures. They are classified as: undisplaced, deviated, displaced (with medial or lateral overlap) and dislocated. The management of mandibular condylar fractures remains controversial. A wide spectrum of management is seen from plain analgesic, to physiotherapy, intermaxillary fixation and open reduction with internal fixation. Over the past decade better understanding of biological considerations of condylar fractures, improved surgical facilities and skills have tilted the balance in favor of open reduction. Open reduction is usually carried out by extra-oral approach such as preauricular, submandibular and retromandibular. Various modifications have been proposed for retromandibular approach like transparotid, transmasseter, high cervical transmasseteric anteroparotid, and mini retromandibular. This talk will present our experience with the retro-parotid transmasseteric approach to condylar fractures through mini-retromandibular access. This approach minimizes nerve injury and provides good access. Materials and Methods: From 2004 to 2010 a total number of 46 patients with a total of 51 condylar process fractures were treated with open reduction and internal fixation. Male patients were 36 and female 10 with an age range from 18 years to 52 years. Mean age was 32 years. The mechanism of injury was either motor vehicle accident, falls or assault. 7 cases were high condylar neck fractures, 28 low condylar neck and 16 were subcondylar fractures. Bilateral condylar fractures were 5. Condylar fractures associated mid-face fractures were 6, mandibular ramus and coronoid process 1, mandibular body and parasymphysis 29 and isolated condyle 15. Diagnosis was made on clinical and radiographic picAAOMS • 2011
tures, making use of panorex views, mandibular series x-rays and coronal CT scans. Indication for surgery included shortened posterior mandibular height, premature contact of molar teeth, presence of malocclusion like crossbite and anterior open bite and patient willingness through informed consent. All patients were operated on using retroparotid tranamasseteric approach through mini retromandibular incision measuring between 1.5 to 2 cm. Maximum follow-up period was 4 years. Methods of Data Analysis: Descriptive statistics, Minitab 13. Results of Investigation: Good results were achieved. Posterior mandibular height was restored in all except one. No mandibular deviation was observed on opening in 45 patients. Occlusion and range of mandibular motion was found to be satisfactory. Facial symmetry was achieved in all patients. Transient facial nerve injury was noted in 4 patients which completely resolved in 6 to 8 weeks. One patient with bilateral facture encountered postop infection on one side which was treated with antibiotics. Salivary fistula was present in 2 patients treated conservatively. Temporoandibular joint pain was reported by 3 patients of whom 2 were known to have nocturnal buxism. Condylar dislocation post ORIF was seen in 1 patient who experienced an epileptic fit. One plate was found fractured on a review appointment 12 weeks postop. All patients had minimally visible scar. Conclusion: Open reduction of condylar fractures through retroparotid transmasseteric approach via miniretromandibular access provides adequate exposure and reduction, minimal nerve injury and minimal visible scar. References: High Cervical Transmasseteric Anteroparotid approach for open reduction and internal fixation of condylar fractures. J Oral Maxillofac Surg.66:201-204.2008 Clinical followup examination of surgically treated fractures of the condylar process using transparotid approach. J Oral Maxillofac Surg: 68.611-617,2010
Subcranial Navigation-Assisted Repair of Frontobasal Skull Fractures S. Gelesko: Oregon Health and Science University; Legacy Emanuel Medical Center, R. Bell, E. Dierks, B. Potter Statement of the Problem: The management of frontobasar fractures with orbital roof involvement has historically been transcranial, with multiple potential complications including brain injury, significant bleeding, and poor esthetic outcomes. The primary objective of this retrospective cohort study was to determine whether displaced frontobasal skull fractures involving the orbital roof may be safely and successfully repaired via a navigation-assisted transorbital approach. The sece-37